Minnesota Hearing Healthcare Providers

Membership Application / Renewal Form

[X] Preferred mailing address [ ] Business [ ]Residential (default)

Name________________________________________________________________________________

Res. Address________________________________________________________________________

City _____________________________________ State_______ Zip ____________-______________

Res. Phone _____________________________Birthday(M)_______/(D)_______/(Y)____________

Dispensing Since(M)_____/(Y)_____ Also in State of______Lic.No._____________________

Credentials (Check all that apply) [ ] HIS [ ] CCC-A [ ] BC-HIS [ ] Other _______________________

Bus. Name__________________________________________________________________________

Bus. Address________________________________________________________________________

City _______________________________________ State_______ Zip __________-______________

Bus. Phone ______________________________FAX No.____________________________

e-mail Address _______________________ Website Address____________________________

Position (Check all that apply) [ ] Owner [ ]Dispenser [ ] Trainee [ ] Trainee Supervisor

”I hereby agree to comply with the MHHP Inc By-laws and the I.H.S. Code of Ethics. I further agree to support the

goals, ideals, and activities promoted by the MHHP Inc for the well-being, professionalism, and effectiveness of its

members in the conduct of their business. I understand that failure to do so may because for denial of my

Application or recall of my membership in the MHHP Inc.

Signature ________________________________________Date ________/________/_____________

Membership Dues Amount is $150.00 Deadline is January 31, 2010 Late Fee is $50.00

Enclosed find check #_________ in the amount of $___________ made payable to MHHP Inc

Mail to:

MHHP Inc, 903 Hwy 15 South, Suite #100, Hutchinson, MN 55350